Nursing Care Plan Using the Nursing Process
Student Name: Chasiti Falls
Date: 09/12/2011
Client’s Initials: ACD
Assessment (Client Story- Reason for Admission, Course of Stay, Medical/Surgical History, Current Assessment Findings (OB or Peds)
Vital Signs, Current Laboratory/Radiology Results, Current Medications, Support System, )
Reason for Admission: Undelivered Pregnancy
Course of Stay: 09/10/2011 – 09/13/2011
PMH: HSV  no current lesions; low-lying placenta – all clear at 26 weeks ; On 04/13/11 c/o palpitations/heart pounding & syncope c SOB –
Sent to ER – no results found
Allergies: Amoxicillin
Current Assessment:
GTPAL:1,1,0,0,1
5’7” 230lb BMI: 36.0 – Prior pregnancy weights not listed, but have been educated on nutrition during discharge teaching. Nutritional needs
similar to when pregnant. Need energy (calories), protein, calcium (emphasized greatly), iodine, zinc, the B vitamins, and vitamin C.
Delivery time: 1819 on 9/10/2011
Type of delivery: c/s lower uterine transverse
Epidural (spinal) given at 1810
Membrane of ROM: spontaneous at 0900 on 09/10/11; Fluid clear
Placenta: Manual removal at 1820 on 09/10/11
Blood Loss: > 500mL  aeb low RBC, Hct, Hgb, & Plt counts
Presentation: Cephalic
Cephalic Position: Vertex
Blood Type: O positive
RhoGam: positive
Rubella Status: Immune
Tdap: 11-18-08
Physical Assessment:
Breast: soft, nipples sore, no cracking, no bleeding
Uterine Fundus: Firm, U/1
Bowel: active * 4 quadrants; Last BM on Friday, 09/08/11; Flatulence present; Slight tenderness on palpation of uterus. Pt. states 2/10 pain
rating prior to palpation. The pain 2/10 does not hinder pt. ability to function. 2 Percocet given on request at 0850. Follow up assessment
findings were that comfort function level was maintained but not reduced.
Bladder Status: Voiding Freely; on I&O till 11:15 A on 09/12/11
Lochia: light rubra
Episiotomy/Cesarean Incision: CDI c Steri Strips
Hemorrhoids: None
Edema: None
Breastfeeding – Effective; however, on the night shift, mother was anxious and tried to feed the infant too often. Baby would not latch & got
fussy and mother did not understand why. She was educated on the matter, sent the baby to the nursery to get some rest. No problems noted
on our shift.
I&O: Void- 600cc; Intake: 480mL
CV: S1, S2 present. Regular rate & rhythm.
Lungs: Chest wall symmetrical with equal expansion. Respiration regular, unlabored, & symmetrical. CTA.
ADL’s: Able to complete all ADL’s on her own, no limitations. Showered, got dressed, and walked to gift shop.
VS:
Temperature: 98.6 degrees Fahrenheit
BP: 104/64
Pulse: 80
Respirations: 16
Medications:
Colace 100mg PO BID for stool softening
Prenatal Multivitamin PO daily
Ibuprofen (Motrin) 800mg PO Q6H for pain
Valtrex 500mg PO daily for HSV
Oxycodone/APAP 5-325 mg (Percocet) Q4H PRN for severe pain
Support System: Married c no other children. Husband seems eager to participate in infant care as well as that of the mother while limited.
Labs:
WBC (3.7-11.0) – 11.9 H because invasive procedure and incision site.
RBC (4.01-4.0) – 3.31L because blood loss during delivery.
Hgb (12.2 – 15) – 10.1 L because blood loss during delivery.
Hct (35.8-47.9) – 29.8 L because blood loss during delivery.
Plt (150-400) – 141L because of blood loss during delivery.
Readiness for enhanced childbearing process
Readiness for enhanced family processes
Risk for constipation r/t pain medications
Risk for Postpartum Depression r/t anxiety
Activity Intolerance r/t surgical incision aeb fatigue & pain
Risk for Infection r/t incision
Knowledge Deficit of Postpartum Care r/t being first time mother aeb asking lots of questions & anxiety
Acute Pain r/t tissue damage aeb pain rated 2/10
Risk for fluid deficit d/t postpartum hemorrhage
Fatigue r/t anxiety and giving birth aeb forgetfulness
Impaired Tissue Integrity r/t caesarean aeb incision with Steri strips
Anxiety r/t knowledge deficit along with being first time mother aeb early morning breastfeeding, separation anxiety during the night, and
being unable to sleep
Nursing
Diagnoses/Analysis
(List 2 Nursing Diagnoses
in Order of Priority; 3-part
statement for actual
diagnoses)
Anxiety r/t change in role
function to a first time
mom aeb over feeding the
baby, and pt. stated that
she was unable to sleep
because she didn’t want to
send infant to nursery
Planning
(Expected Client
Outcomes)
Will identify and
verbalize symptoms of
anxiety while on my
shift.
Will identify, verbalize,
and demonstrate at least
2 techniques to control
anxiety while on my
shift.
Will verbalize absence
or decrease in subjective
distress while in my
shift.
Activity Intolerance r/t
cesarean aeb fatigue and
pain
Will appear relaxed
through having
appropriate posture,
facial expressions,
gestures, and activity
levels that reflect
decreased distress while
on my shift.
Will be able to increase
activity gradually while
on my shift. i.e. Getting
out a bed, showering,
dressing, walking in
halls.
Incision site will remain
CDI while on my shift
Will get enough rest to
function both physically,
mentally, and
emotionally.
Will state symptoms of
adverse effects of
excessive activity and
report onset of
symptoms immediately
while on my shift.
Implementation
(Nursing Activities with NIC
Intervention
Label & Page # Tailored to
Your Client)
Anxiety Reduction p. 144
Educate pt. on how to care
for herself and the baby.
Educate pt. on SIDS, and to
put the baby down when
getting distraught.
Evaluation
(Evaluate Each Expected Client
Outcome-If Not Met Discuss Reason
and Proposed Changes in Client Care)
Goal met aeb anxiety level appeared
to decrease after discharge teaching.
Pt. verbalized that she felt more
comfortable after becoming
knowledgeable of anxiety and
soothing techniques.
Educated pt. on the
importance of limiting
visitors and getting lots of
rest.
Assess for signs of distress
and its interference c ADLs
q2h.
Educate pt. on both
pharmological and
nonpharmological methods to
use to decrease and/or control
anxiety such as massage,
music, and medication.
Energy Management p. 119121
Educate pt. on the adverse
effects of too much activity.
Educate pt. on what she
should and should not do, and
to gradually increase activity.
(i.e. do not lift heavy objects,
do not drive for two weeks, do
rest when baby allows, etc.)
Educate pt. and show how to
care for incision site with
soap & water.
Infant will be taken to the
nursery in order for the
mother to get rest.
Assess client’s ability to
tolerate activities.
Goal met aeb discharge teaching
performed and questions answered
about activity tolerance. Pt. got out
of bed, showered, got dressed, and
walked to the gift shop after getting
some rest. Incision site remains
CDI. Pt. notifies staff of pain
rating 2/10 after activity, no
increase.
Nursing Care Plan Using the Nursing Process
Student Name: Chasiti Falls
Date: 09/12/2011
Client’s Initials: ACD NBF
Assessment (Client Story- Reason for Admission, Course of Stay, Medical/Surgical History, Current Assessment Findings (OB or Peds),
Vital Signs, Current Laboratory/Radiology Results, Current Medications, Support System, )
Reason for Admission: NBF
Course of Stay: 09/10/2011 – 09/13/2011
PMH:
Delivery time: 1819 on 9/10/2011
Type of delivery: c/s lower uterine transverse
Membrane of ROM: spontaneous at 0900 on 09/10/11; Fluid clear
Presentation: Cephalic
Cephalic Position: Vertex
Resuscitation: Tactile Stim, Bulb Suction
Live born
Term 38.5 weeks
Stable
APGAR: 1 minute – 9; 5 minutes – 9
9lb 15oz
Head 36”
Length: 22”
LGA: Yes
Mother’s Blood Type: O positive
Mother’s RhoGam: positive
Mother’s Rubella Status: Immune
Mother’s PMH: HSV  no current lesions; low-lying placenta – all clear at 26 weeks ; On 04/13/11 c/o palpitations/heart pounding &
syncope c SOB – Sent to ER – no results found
Allergies: NKA; NKDA
Current Assessment:
Identification band present/security tag active: yes
Breastfeeding: Not cooperative early AM; 1015 left breast – 5 minutes; 1050 right breast – time unknown (Parents were unable to remember,
we provided them a breastfeeding tracking sheet)
Scalp Petechiae
Mldg
ORS
Erythema on nape & eyes
Generalized NBR
Red dot c possible bruising to back of left thigh
Scratch inside left ear
Cracking ankle – lotion applied
Vaginal Discharge
CV: Regular rate & rhythm. No murmurs heard.
GI: BS active *4 quadrants.
Lungs: CTA. Chest wall symmetrical with equal expansion. Respiration regular, unlabored, & symmetrical.
VS:
Temperature: 98.3 degrees Fahrenheit
Pulse: 138
Respirations: 40
Support System: Married Mother & Father c no siblings. Parents both seem to have formed a loving bond with the infant and eager to provide
satisfactory care.
Risk for Jaundice r/t jaundice surfacing around 3rd or 4th day
Risk for Ineffective Thermoregulation r/t immaturity
Risk for Ineffective Airway Clearance r/t excessive oropharyngeal mucous
Risk for Infection r/t inadequate acquired immunity
Effective Breastfeeding r/t infant gestational age >34 weeks aeb sucking, latching, and appears to be full
Readiness for Enhanced Organized Infant Behavior aeb
Nursing
Diagnoses/Analysis
(List 2 Nursing Diagnoses
in Order of Priority; 3-part
statement for actual
diagnoses)
Risk for Ineffective
Airway Clearance r/t
excessive oropharyngeal
mucous
Planning
(Expected Client
Outcomes)
Implementation
(Nursing Activities with NIC
Intervention
Label & Page # Tailored to
Your Client)
Evaluation
(Evaluate Each Expected Client
Outcome-If Not Met Discuss Reason
and Proposed Changes in Client Care)
Infant will maintain a
patent airway at all
times while on my shift.
Teach parents taught how to
use bulb syringe immediately.
Goal met aeb infant maintained
patent airway, demonstrated how to
use bulb syringe, and able to
identify factors that can inhibit
effective airway.
Parents will
demonstrate how to use
bulb syringe while on
my shift.
Parents will identify
factors that can inhibit
effective airway
clearance while on my
shift.
Effective Breastfeeding r/t
infant gestational age > 34
weeks aeb latching,
sucking, and appears to be
full.
(I chose this not as a
priority diagnosis, but
because I had not
completed a care plan on
it yet.)
Infant will maintain
effective breastfeeding
during my shift.
Infant will maintain
normal growth patterns
while on my shift.
Mother will verbalize
satisfaction with
breastfeeding process
while on my shift.
Assess infant for patent
airway q2h.
Educate parents on factors
that inhibit effective airway
clearance such as smoking
during discharge teaching.
Encourage skin-to-skin
contact.
Encourage breastfeeding on
demand.
Provide mother with written
record to monitor
breastfeeding sessions.
Assess nipples for pain,
soreness, and irritation.
Provide Lanolin prn.
Assess infant weight daily.
Goal partially met aeb infant
breastfeeding well, and mother
satisfied. Weight taken on night
shift, but I did not get to retrieve
that information from computer
thus, I cannot confirm that the
infant maintained normal growth
patterns.
Reflection and Critical Thinking Questions Based on QSEN Competencies (http://www.qsen.org):
1. What are your personal views on today’s clinical experience? What would you do
differently to be more successful with your client? What quality improvement methods
could be instituted to improve the client’s quality of care and safety?
I thoroughly enjoy clinical. I love the MB unit! It is a lot faster pace than Illness & Disease
Practicum. I have always wanted to work in this department and still do, but I have heard that
you do not learn as much as a new graduate because everything is so repetitive. I have become
more comfortable with the assessments, though not as comfortable as I would like. With
practice, I am sure I will become more competent and confident. . A quality improvement
would include having us invest in pediatric sized stethoscopes and having a designated person to
fill in for sitters for breaks. It was somewhat chaotic when the sitter needed to take a break. As
for safety, the HUG alarms and bracelets are effective. One thing I have noticed is that the
electric doors especially at the nursery stay open for a long time. This could allow time for an
unauthorized individual to get in there.
2. Discuss your client’s disease pathophysiology and relate it to the assessment findings
(including vital signs, laboratory results, and medications). Please support your answers
using appropriate nursing literature- including nursing research and evidence based
practice literature. Based on your client’s current pathophysiology or personal/family
disease history, describe the genetic or genomic education, screening, or referral that you
could perform with your client/family during your nursing care.
Acute Pain is “usually of recent onset and commonly associated with a specific injury, acute pain
indicates that damage or injury has occurred (Brunner & Suddarth p.231).” The pulmonary,
cardiovascular, gastrointestinal, endocrine, and immune systems can be affected by unalleviated
pain. While a young, healthy person could probably bear these effects, an elderly or immunecompromised individual are at a disadvantage for successful recovery. The pain needs to be
handled effectively, thus making the recovery process quicker and more successful (Brunner p.
232). As healing occurs, the acute pain should be reduced (Brunner p. 231). Aggravating &
both pharmacological and non-pharmacologic alleviating factors need to be determined in order
to provide effective care. “A first-degree laceration extends through the skin and structures
superficial to muscles (Lowdermilk p.470).” Our skin is a primary defense mechanism making
the patient more susceptible to infection. If the patient were to have another child, then she may
want to have a caesarean birth to avoid reinjury. Substantial bleeding is expected due to the
vascularity of this area. An injury like this usually heals without lasting damage.
3. What were your client/family’s educational needs and what strategies did you use to meet
the needs? How did you utilize informatics to educate your client/family? What did you
document about your education success or difficulties today?
My family was first time parents. Kassie & I completed discharge teaching. Strategies we used
were providing them a book to follow along as we talked demonstration of bulb syringe use, and
making the teaching more of a conversation rather than lecture. We also had to provide them the
Purple Cry DVD thus we incorporated informatics such as a TV & DVD player. Today was the
first day I actually did the teaching myself. I need to be more knowledgeable of the discharge
notebook; thus, I am going to obtain a copy and highlight the most important bullet points that
need to be taught.
4. Discuss 3 patient-centered care actions that you performed today that demonstrated
caring towards your client/family. Were they based on the client/family’s preferences,
values, and needs?
Though it is our job to tidy the patient’s room already, I helped her pick up the bathroom after
she showered including her own personal belongings. I provided her with extra linens even
though she said it was not necessary because her husband had already showered with them.
After teaching her on anxiety and the importance of her obtaining some rest, I took the baby to
the nursery. I checked on the couplet frequently and provided care and/or support as needed.
When doing my assessment I made sure to inform the patient of what I was doing and to
maintain privacy. Talking to my patient was a diversion activity that calmed her down. These
actions were value and need based.
5. Discuss how inter-professional teamwork & collaboration was used to care for your
client or discuss how your client might have benefitted from better inter-professional
teamwork & collaboration practices.
Student nurses are great to have on any floor. Not only is it educational for the students, another
hand for the nurses, but a great emotional support for the patient. As students, we have a lot
more time to spend with our patients providing them with just a little something special. I
enjoyed working with Kassie. When doing assessments we would do them synchronized to
avoid having the patient undergo two assessments. We would compare allowing me to
determine my competence. Kassie speaking me through procedures & being in the room
probably calmed the patients down knowing that I am a student with little experience. I did what
Kassie asked such as gathering equipment, taking VS, and simply being eager to work, and then
in return, Kassie provided me with an educational experience.